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Office of the President University of Massachusetts NOTICE OF INJURY/ILLNESS REPORT This form is intended for internal use for all Human Resources Division/Workers' Compensation Unit user agencies

How to fill out notice of injuryillness report

How to fill out notice of injury/illness report:

1. Begin by entering your personal information, including your full name, contact information, and job title or position.
2. Provide details about the injury or illness, including the date and time it occurred, the location, and a brief description of what happened.
3. Indicate whether the injury resulted in time away from work or required medical treatment. If so, provide information about the healthcare provider or facility visited and any relevant medical records or documents.
4. Include the names and contact information of any witnesses who can corroborate your account of the incident.
5. If applicable, attach any supporting documentation such as photographs, incident reports, or safety violation reports.
6. Sign and date the notice of injury/illness report, certifying that the information provided is true and accurate to the best of your knowledge.

Who needs notice of injury/illness report:

1. Employees who have experienced a work-related injury or illness should fill out the notice of injury/illness report.
2. Employers may also require their employees to submit a notice of injury/illness report as part of their internal processes and to ensure compliance with legal requirements.
3. In some cases, specific industries or occupations may have regulations that mandate the submission of these reports to relevant authorities for record-keeping and investigation purposes.

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What is notice of injuryillness report?

The notice of injury/illness report is a document that is used to report any workplace injuries or illnesses. It is a form that employers must fill out and submit to the appropriate authority.

Who is required to file notice of injuryillness report?

Employers are required to file the notice of injury/illness report. They are responsible for reporting any workplace injuries or illnesses that occur to their employees.

How to fill out notice of injuryillness report?

To fill out the notice of injury/illness report, employers need to provide details about the injured or ill employee, such as their name, job title, and contact information. They also need to describe the nature of the injury or illness, the date and time it occurred, and any medical treatment provided.

What is the purpose of notice of injuryillness report?

The purpose of the notice of injury/illness report is to ensure that workplace injuries and illnesses are properly documented and reported. This allows for appropriate action to be taken, such as providing medical treatment to the affected employee and implementing measures to prevent similar incidents in the future.

What information must be reported on notice of injuryillness report?

The notice of injury/illness report must include information about the injured or ill employee, such as their name, job title, and contact information. It should also detail the nature of the injury or illness, the date and time it occurred, any medical treatment provided, and any witnesses to the incident.